Iliac vein recanalization: When and how?

Oliver Schlager

Division of Angiology,

Department of Medicine II

Medical University of Vienna

Austria

Disclosure

Speaker name:

Oliver Schlager

I have the following potential conflicts of interest to report:

Consulting (Optimed, BARD/BD)

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

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35 year-old male patients with severe pain and swelling oft left leg,

sudden onset 6-8 hours ago.

Uneventful medical history.

Case 1

Boston Scientific

Case 1

May R, Thurner J. Angiology 1957;8(5):419-27

www.veinguide.com

May-Thurner-Syndrom

VIDIO trial (multiplane venography vs. IVUS): 26% of obstructions NOT detected by venography

Gagne PJ et al. J Vasc Surg Venous Lymphat Disord 2017;5:678-87

Gagne PJ et al. J Vasc Surg Venous Lymphat Disord 2018;6:48-56

Case 1

Kahn SR et al. J Vasc Surg Venous Lymphat Disord 2020

ATTRACT study

Randomization (1:1)

PMT-arm

5 days of parenteral AC,

immediate bridge to warfarin

(INR 2.0-3.0)

5 days of parenteral AC,

concurrent PMT, then bridge to

warfarin (INR 2.0-3.0)

Conservative-arm

Vedantham S et al. N Engl J Med 2017

Postthrombotic syndrome

Vedantham S et al. N Engl J Med 2017

Notten P et al. Lancet Haematol 2020

- Mixed study population (including IF-DVT and FP-DVT)

- No systematic use of IVUS

- Low stentrate (28%)

- No systematic use of dedicated venous stents

- Binary endpoint analysis

Limitations ATTRACT

- Underpowered (withdrawal of informed consent, loss of follow-up)

Limitations CAVA

Limitations both studies

37 year-old male patients with chronic leg swelling, feeling of heaviness,

Venous claudication (pain-free walking distance 70 m)

History of DVT of right leg including IVC 5 years ago.

Case 2

Case 2

SVS/AVF guidelines:

ESVS recommendations:

In a patient with inferior vena cava or iliac vein chronic total occlusion or severe stenosis,

with or without lower extremity deep venous reflux disease, that is associated with skin

changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous

leg ulcer (C6), we recommend venous angioplasty and stent recanalization in addition to

standard compression therapy to aid in venous ulcer healing and to prevent recurrence.

[Grade – 1; Level of evidence - C]

In patients with clinically relevant chronic ilio-caval or ilio-femoral obstruction or in patients

with symptomatic non-thrombotic iliac vein lesions, percutaneous transluminal angioplasty

and stent placement using large self expanding stents should be considered. [Grade – IIa;

Level of evidence B]

O‘Donnel TF et al. J Vasc Surg 2014

Wittens C et al. Eur J Vasc Endovasc Surg 2015

CIRSE recommendations:

Patients with CEAP clinical class 3-6 and chronic venous outflow obstruction should be

considered for interventional therapyMahnken AH et al. Cardiovasc Intervent Radiol 2014

Recommendations

Razavi MK et al. Circ Cardiovasc Interv 2015

Nonthrombotic (N=1122)

Acute thrombotic (N=629)

Chronic post-thrombotic (N=1118)

Outcomes after venous stenting

VIRTUS trial

Decrease in VCSS score (4.4 point decrease)

VERNACULAR trial

Improvement in VCSS score and CIVIQ-20 score (p<0.0001)

Dake M presented @ LINC 2019 & CIRSE 2019

Razavi M presented @ LINC 2019

Conclusions

- Individual decision making (weighing risks against benefits)

- Equipment-Expertise-Environment

- Reducing the burden of the postthrombotic syndrome

- Close post-interventional follow-up and anticoagulation management

Iliac vein recanalization: When and how?

Oliver Schlager

Division of Angiology,

Department of Medicine II

Medical University of Vienna

Austria